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Uses and Administration Adverse Effects and Precautions Interactions 1518 Cardiovascular tion of benefit in preventing restenosis, 5 although robust 5. Gomberg-Maitland M, et al. Efficacy and et al. Dose proportionality of treprostinil sodium evidence is scanty and studies are ongoing. 5·6 treprostinil in pulmonary hypertension. continuous subcutaneous and intravenous infusion. J 6. Fernandez B, Strootman D. The prostacyclin analog, treprostinil sodium, 48: I 9-2 5. 1. Okamoto S, et al. Effects of trapidil (triazolopyrimidine), a platelet- provides severe Buerger's disease-a case report and derived growth factor antagonist, in restenosis after 2006; 57: 99-I02. percutaneom transluminal coronary Heart J 1992; treprostinil for treatment of chronic 123: 1439-44. pulmonary arterial hypertension. Ann InternMed 2006; 144: 149-50. 2. Maresta A, et a!. Trapidil (triazolopyrimidine), a platelet-derived growth 8. Channick RN, et al. Safety and efficacy of inhaled treprostinil as add-on ProprietaryPreparations (details are given in Volume B) factor antagonist, reduces restenosis after percutaneous transluminal to bosentan in pulmonary arterial hypertension. J Am Coli results of the randomized, double-blind STARC 48: 1433-7. study. 90: 2710-15. 9. Voswinckel R, et at. Favorable effects of inhaled treprostinil in severe Single-ingredient Preparations. Arg.: Remodulin; Austral.: 3. Maresta A, et al. Stare It a multicenter randomized placebo-controlled pulmonary hypertension: results from randomized controlled pilot Remodulin; Austria: Remodulin; Belg. : Remodulin; Canad.: double-blind clinical trial of trapidil for 1-year clinical events and studies. JAm Coil Cardio/ 2006; 48: 1672-81. Remodulin; Chile: Rernodulin; Cz. : Remodulin; Denm.: Remo­ restcnosis reduction after coronary angioplasty and I 0. Skoro-Sajer N, L dulin; Fin.: Remodulin; Fr. : Remodulin; Ger.: Remodulin; Gr.: 64: 375-82. hypertension. Remodulin; Israel: Remodulin; Tyvaso; Ital. : Remodulin; Neth.: 4. 11. Voswinckel R, Remodulin; Norw.: Remodulin; Port.: Remodulin; Swed. : Remodulin; Switz.: Remodulin; USA: Remodulin; Tyvaso. 12. Hiremath J, et al. TRUST Study Group. Exercise improvement and 5. Khan M, et a!. Intrepide; Trapidil eluting stent. Eurolntervention 2008; 4: plasma biomarker changes with intravenous treprostinil therapy for 405-1 1. pulmonary arterial hypertension: a placebo-controlled trial. J Hea!1 Lung 6. Iaccarino D, et a!. Rationale and study design ofthe OISTER trial: Optical Transplant 2010; 29: 137-49. coherence tomography evaluation of stcnt struts re-endothelialization I 3. McLaughlin VV, et al. Addition of inhaled treprostinil to oral therapy for coronary syndromes-a pulmonary arterial hypertension: a randomized controlled clinical trial. taxus drug- JAm Coll Cardiof 2010; 55: I915-22. eluting stent ll: 536- 43. Administration. A study1 in 23 patients with pulmonary hypertension who were treated with subcutaneous infu­ Preparations sion of treprostinil found that a rapid dose-escalation regi­ Proprietary Preparations (details are given in Volume B) men (weekly or twice-weekly increments of 2.5 nano� grams/kg per minute) lowered infusion-site pain and Single-ingredient Preparations. Braz.: Travisco; Ger. : Rocornal; improved 12-week exercise outcomes without increasing Ital. : Travisco; Jp n: Rocornal. adverse events when compared with a slower dose-escala­ tion regimen (weekly increments of 1.25 to 2 nano­ grams/kg per minute). NOTE. Compounded preparations of triamterene may be Treprostinil !USAN, riNN! l. et al. A clinical comparison of slow- and rapid-escalation in patients with pulmonary hypertension. represented by the following names: 47: 611-18. Co-triamterzide (BAN)�triamterene 2 parts and hydro­ 15AU81; B\lllci:,iAU; • Trepr0stinilo; TrE!Pf<)Stinilt;m; chlorothiazide I part (w/w) Administration in hepatic impairment. Clearance of tre­ Co·triamterzide (PEN)-triamterene and hydrochloro- Tpenpor:n1H>U1. • . ({(lR,2R,3a5,9a5)· 2,3,3 a.4;9,9a -Hexahydro-2-hydroxy" l -[(35)-3- prostinil is reduced in patients with hepatic impairment. thiazide. Licensed product information recommends that the initial hyctr()O:.Yottyi)'l.H'benz��lr.den·S'yi.lof)')acetic a.cid. Pharmacopoeias. In Chin., Bur. (sec p. vii), Jpn, and US. C23H,o,,,39Q.5 dose of the infusion should be 0.625 nanograms/kg per minute, and should be increased cautiously, in mild to Ph. Eur. 8: (Triamterene). A yellow, crystalline powder. CAS Very slightly soluble in water and in alcohoL Protect from :... si846cll).7 moderate impairment. No licensed dosage recommenda­ ATC ·� light. BOiAC2 1. tions are given for severe hepatic impairment. However, ATC Vet � QBG IAC!L intravenous treprostinil infusion was reported 1 to be safe USP 36: (Triamterene). A yellow, odourless, crystalline t/Ni! '- RUM6K67E5G. and effective in 3 patients with end -stage liver disease, powder. Practically insoluble in water, in chloroform, in including I patient who was given 106 nanograms/kg per ether, in benzene, and in dilute alkali hydroxides; very Treprostinil Sodium (r/NNMJ minute for 2 years. slightly soluble in alcohol, in acetic acid, and in dilute Caution is also advocated when titrating upwards from mineral acids; soluble l in 30 of formic acid and l in 85 of 2· the initial dose of inhaled treprostinil in patients with mild to methoxyethanol. Store in airtight containers. Protect from moderate hepatic impairment. light. l. Sakai T, et al. Initial experience using continuous intravenous treprostinil to manage pulmonary arterial hypertension in patients with end-stage liver disease. Transpi lnt 2009; 22: 554--61. Uses and Administration Triamterene is a weak diuretic with potassium -sparing Peripheral vascular disease. Prostaglandins have been properties which has actions and uses similar to those of used for their vasodilating effect in the treatment of per· amiloride (p. 1299.1). It produces a diuresis in about 2 to 4 ipheral vascular disorders (p. 1272.3), although their role hours, with a duration of 7 to 9 hours. The full therapeutic remains unclear. They may be of benefit in severe Ray­ Uses and Administration effect may be delayed until after several days of treatment. naud's syndrome (see Vasospastic Arterial Disorders, Triamterene adds to the natriuretic but diminishes the Treprostinil, a vasodilator and platelet aggregation inhibitor, p. 1275.3) that is complicated by ulceration, and subcuta· kaliuretic effects of other diuretics. It is mainly used, as an is an analogue of the prostaglandin epoprostenol (prosta- � neous treprostinil was used1 successfully to treat severe adjunct to thiazide diuretics such as hydrochlorothiazide cyclin; p. 137 4. 3) and is given in the treatment of 1 refractory digital necrosis in a patient with Raynaud's dis­ pulmonary hypertension (p. 1278.2). Treprostinil sodium is ease and scleroderma. and loop diuretics such as furosemide, to conserve given by continuous subcutaneous infusion; if this route potassium in those at risk from hypokalaemia during the 1. Engel G, Rockson SG. Treprostinil for the treatment of severe digital cannot be tolerated, treprostinil sodium may be given by necrosis in systemic sclerosis. Vase Med 2005; 10: 29-32. treatment of refractory oedema associated with hepatic continuous infusion through a central venous catheter. cirrhosis, heart failure (p. 1262.3), and the nephrotic Doses are calculated in terms of treprostinil: treprostinil syndrome. It is also used with other diuretics in the sodium 1.32 nanograms is equivalent to about 1.25 nan­ Adverse Effects and Precautions treatment of hypertension (p. 1251.1). ograms of treprostinil. The infusion is started with a dose As for Epoprostenol, p. 1375.3; infusion-site reactions are When triamterene is given alone in the treatment of equivalent to treprostinil 1.25 nanograms/kg per minute; if common. Inhaled treprostinil has been associated with signs oedema, the oral dosage range is 150 to 250 mg daily, given this is not tolerated the dose should be halved. The infusion of local irritation including haemoptysis (fatal in one case), in 2 divided doses, after breakfast and lunch. Doses may be 1 rate can be increased according to patient response, by and pneumonia. Treprostinil should be used with caution in given on alternate days for maintenance therapy. More increments of up to 1.25 nanograms/kg per minute each hepatic impairment. than 300 mg daily should not be given. week for the first 4 weeks, followed by increases of up to Smaller doses are used initially when other diuretics are 2.5 nanograms/kg per minute each week. There is limited also given. When used with hydrochlorothiazide, for experience with doses above 40 nanograms/kg per minute. Interactions example, in the treatment of hypertension, an initial dose Treprostinil may also be given by inhalation in an initial Since treprostinil is a vasodilator and inhibitor of platelet of 50 mg of triamterene daily may be used. dose of 18 micrograms inhaled 4 times daily, reduced to 6 or aggregation, care should be taken in patients receiving other Potassium supplements should not be given. 12 micrograms inhaled 4 times daily if the higher dose is not vasodilators or anticoagulants. tolerated. Dosage should then be increased in increments of I 8 micrograms every I to 2 weeks as tolerated, to a Pharmacokinetics Adverse Effects maximum maintenance dose of 54 micrograms inhaled 4 As for Amiloride Hydrochloride, p. 1299.2. Triamterene has times daily. Treprostinil sodium is rapidly and completely absorbed after also been reported to cause photosensitivity reactions, The dose of treprostinil should be reduced in hepatic
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